CONFIDENTIAL HEALTH HISTORY FORM

Have you ever received a professional massage? ______Date of last massage: ______

What type of pressure do you prefer during your massage? __ Light __ Moderate __ Deep

List stress reduction and exercise activities including frequency: ______

______

MEDICAL HISTORY (Include year and treatment received):

Are you currently seeing a medical practitioner? ______If yes, please explain: ______

List current medications including: aspirin, ibuprofen, herbs, supplements, etc.: ______

______

______

Allergies:______

Accidents/Injuries/Illnesses/Surgeries: ______

______

______

Contacts? ______Dentures? ______Transdermal patches (nicotine)? ______IV Port? ______

Please place a check mark in the past and/or current box next to any items that apply to your health history.

Musculoskeletal:

Past / Current / Condition / Past / Current / Condition / Past / Current / Condition
Lupus / Head Injury / Jaw Pain
Bone/Join Disease / Spasms/Cramps / Neck Pain
Bursitis / Broken/Fractures bones / Shoulder Pain
Tendonitis / Sprains/Strains / Arm Pain
Rheumatoid Arthritis / Other / Low Back Pain
Osteoarthritis / Hip Pain

Circulatory:

Past / Current / Condition / Past / Current / Condition / Past / Current / Condition
Heart Condition / High Blood Press. / Lymphedema
Blood Clots / Low Blood Press. / Varicose Veins

Skin:

Past / Current / Condition / Past / Current / Condition / Past / Current / Condition
Allergies / Rashes / Athlete’s Foot
Warts

Nervous System:

Past / Current / Condition / Past / Current / Condition / Past / Current / Condition
Numbness/Tingling / Herpes/Shingles / Sleep Disorders
Chronic Pain / Fatigue / Other:

Digestive/Urinary System:

Past / Current / Condition / Past / Current / Condition / Past / Current / Condition
Constipation / Diverticulitis / Kidney/Bladder
Gas/Bloating / Irritable Bowel Syndrome

Respiratory System:

Past / Current / Condition / Past / Current / Condition / Past / Current / Condition
Asthma / Breathing Difficulty / Allergies
Sinus Problems / Other:

Reproductive & PMS:

Past / Current / Condition / Past / Current / Condition / Past / Current / Condition
Bloating / Mood Swings / Painful Periods
Cramps/Pain / Breast Tenderness / Irregular Periods
Pre-menopausal or Menopausal Symptoms / Pregnancy –If current, # of weeks? / Absent Periods

Please read each section and initial and date at the end of each.

It is my choice to receive massage therapy; I realize that the massage is being given for the well-being of my body and mind. This includes stress reduction, relief from muscular tension, spasms and or pain. I agree to openly communicate with my practitioner during my session (e.g., comfort on table, pressure, safety, etc.). Initials: ______Date: ______

I understand that massage therapists do not diagnose illness, disease or any physical or mental disorder; nor do they prescribe medical treatment, pharmaceuticals or perform spinal thrust manipulations. I acknowledge massage is not a substitute for medical examination or diagnosis and it is recommended that I see a primary health care provider for that service. I stated all medical conditions I am aware of and will update my health statues with my therapist. Initials: ______Date: ______

I agree to cancel my scheduled appoint at least 24 hours in advance. I understand that less than 24-hour notice will result in billing for my dedicated appointment time. Initials: ______Date: ______

Signature: ______Date: ______

204 Delaware Avenue, Delmar, NY 12054 ~ 518-577-5488 ~ www.labergemassagetherapy.com